HEART: Application For Residence
We unfortunately are unable to provide crisis housing at this time, if you are in crisis please call Crisis Intervention: (717) 394-2631 or 211

Please allow 48 hours for us to review your application and respond to you.
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Email *
Full Legal Name *
Chosen/Actual Name (If different)
Form Completed By (If someone other than client)
Date of Birth *
Age *
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Sexual orientation
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Phone Number
Emergency Contact
Relationship to Emergency Contact
Current/Last Address (Including city, state, & ZIP)
Current Housing Situation
Do you have mental health concerns? (Specify)
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This form was created inside of Lancaster LGBTQ+ Coalition. Report Abuse